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Methods

A cross-sectional web-based anonymous survey was sent to medical students enrolled
at the University of California, Davis (N = 371) with a response rate of 68%.

Results

Few respondents expressed negative attitudes toward gay men or would deny them civil
rights. More negative responses were seen with respect to aspects of intimate behavior
and homosexuality as a natural form of sexual expression. Men and students younger than 25 years old were more likely to endorse negative attitudes
toward behavior as well as more traditional views on male toughness.

Conclusions

We show that an important minority of students express discomfort with the behavior
of gay men and hold to a narrow construction of male identity. These findings suggest
that competency training must move beyond conceptual discussions and address attitudes
toward behaviors through new pedagogical approaches.

Keywords:

Homosexuality; Medical students; Bias

Background

Though medical care in the United States has promoted health and longevity, many disparities
persist even after socioeconomic status and other factors have been accounted for
[1,2]. Sexual minorities are a group for whom disparities in health are prevalent and problematic
[3,4]. Lesbian, Gay, Bisexual, and Transgender (LGBT) individuals are often “invisible”
due to the ability of members to hide their status and thus avoid bias because they
may be construed as “different” from their peers [5,6]. As a result of familial, societal and religious pressures, many LGBT individuals
hide their status and relatively few make their orientation known to their health
care providers. Those who disclose their orientation may find that their physician
is unprepared and even unwilling to discuss same-sex relationships and behavior [7].

Medical educators recognize the need for physicians to understand and interact with
patients of different cultural backgrounds since prejudices of medical students and
physicians have demonstrable and important effects on patient wellness [8]. Often, health care providers are not aware of their biases, which can remain unconscious.
This leads to deleterious patient outcomes due to assumptions that one is heterosexual
and negative caregiver attitudes that are not openly discussed in medical education
settings [9]. Social desirability bias often limits the disclosure of negative attitudes [10,11]. Health care providers who have negative attitudes toward same-sex behavior have
been found to provide inadequate care for LGBT individuals [12]. Furthermore, studies assessing prejudicial reactions of health care providers have
been limited in recent years. In 1982, a questionnaire sent to members of the San
Diego County Medical Society revealed that 23% of respondents exhibited prejudiced
attitudes and 30% would reject a highly qualified gay applicant to medical school
[13]. Another study revealed “low-grade homophobia” among medical students that did not
change significantly despite panel discussions and clinical experiences [14]. A more recent look at San Diego County Medical Society members’ view on gay students
revealed a much decreased prevalence of sexual prejudice, but one that still existed
and was associated with phobias about human immunodeficiency virus infection [15].

The objectives of this study were to determine medical students’ attitudes toward
gay male behavior, persons, civil rights, and male toughness. We chose to focus on
gay men in the context of “masculinity” or “normative” views on male gender roles
because there are no studies to date suggesting that these concepts should be discussed
in medical school lectures. We hypothesized that individuals would not exhibit prejudice
toward a person’s identity, but would exhibit bias when reflecting on the intimate
practices of others. We sought to investigate the prevalence and correlates of negative
attitudes toward gay identity and behavior. We predicted negative attitudes toward
gay men among older students and males based on public surveys suggesting these populations
have more aversive reactions [16].

Method

Setting

The University of California, Davis, School of Medicine has a diverse student enrollment
comprising 25% underrepresented minority students. Approximately 2.3% of students
across all years self-identify as LGBT (personal communication, Office of Diversity).
There is an active LGBT students’ organization within the campus. At the time of this
writing, the University of California, Davis School of Medicine devotes 10 hours of
curricular time to LGBT issues during the course of four years’ training, which is
above the mean hours (5) spent nationally. A survey of medical school deans demonstrated
that 44% of schools provide “fair” instruction in LGBT issues [17]. The medical school curriculum also emphasizes the instruction of culturally sensitive
care through a three-year “Doctoring” curriculum in which students are exposed to
simulated patients from different ethnic and sexual backgrounds. Role-played interactions
trigger feedback and discussion in small groups. In addition, faculty members provide
formal lectures and experiential learning on caring for diverse populations.

Survey generation and scoring

We developed a 20-item survey incorporating items from previously validated instruments
to assess attitudes toward gay behavior, persons, and civil rights [18-21]. In addition, a scale measuring male toughness was included because normative attitudes
on this dimension have been associated in prior studies with negative attitudes towards
gay men [22]. Item selection was refined iteratively to generate the shortest comprehensive instrument.
Each item on the four subscales was rated on a seven point Likert scale from strongly
disagree to strongly agree. Several items on the scale were reverse scored so higher
scores corresponded to more negative reactions. We also recorded the respondents’
sex, age, race/ethnicity, and sexual orientation. Those who identified as LGBT were
excluded from the final analysis due to small numbers (n = 13).

Survey implementation

We conducted a cross-sectional survey of currently enrolled medical students from
December 2010 to January 2011. The study was approved by the University of California,
Davis Institutional Review Board. Online consent included a full description of the
study, including potential harm (no more than minimal but with potential for discomfort).
Participants received no monetary or non-monetary incentive for their participation
in completing the survey and were not required to fill out all questions of the survey.
Questionnaires were sent out to an e-mail listserv used by current medical students.
The message discussed the survey’s intent to better characterize medical student attitudes
toward gay men for the assessment of educational services and development of appropriate
modules in the future. Three reminder e-mails were sent to ensure the highest possible
number of respondents. A subject was recorded as a non-respondent if he or she did
not provide consent after accessing the survey, or failed to fully complete a survey.
The questionnaire was password-secured and available within 60 days from the initial
announcement.

Statistical analysis

The four constructs measured from the survey questions were attitudes toward gay behavior
(behavior), people (persons), civil rights (civil rights), and male toughness (toughness). Constructs were estimated by the sum of the responses to the relevant questions.

The age variable was trichotomized: less than 25 years old, between 25 and 28 years old,
and greater than 28 years old. The race/ethnicity variable similarly had three categories: White, Asian or Other, due to low representation
of racial/ethnic groups other than White and Asian. The sexual orientation variable also had three options: Heterosexual, Homosexual and Bisexual. Homosexual
and bisexual individuals were not included in the final analysis due to their overall
low numbers.

A full exploratory and graphical analysis of the scales was conducted using histograms,
scatterplots and Cronbach’s alpha to assess distribution and linearity assumptions
and scale score reliability, respectively. If the histogram indicated a non-normal
distribution then various transformations were attempted to correct the distribution.
If no transformation appeared to achieve normality or linearity, non-parametric analyses
were used. The Kruskal-Wallis (KW) test of differences in medians was performed to
assess differences in each of the four constructs between the different categorical
variables: gender, race/ethnicity, and age. Additionally, Spearman correlations were calculated to estimate the relationships
between the scales.

There were some missing data due to item non-response. These missing data were imputed
by means of chained equations in R® using multinomial regression, and the complete,
imputed data were analyzed in SAS as above [23,24]. Imputation of missing item responses is necessary to avoid item non-response bias,
a common problem with survey data [25,26]. The imputation was repeated 5 times and each imputed data set analyzed. Analysis
results were compared between the 5 imputations and the original, incomplete data.
If no large differences were observed between the 5 imputations and their analyses,
no correction for multiple imputation variance deflation was performed or presented.

Results

251 out of 371 medical students responded (response rate: 68%). The histograms revealed
a highly skewed, non-normal distribution, thus requiring non-parametric methods to
determine significance. The results of the multiple imputations suggested that there
were no large differences between any of the analyses, with p-values differing only
in the third decimal place. For this reason, the first imputation was used and all
results are from this complete data set.

Respondents had an average age of 27 years (range from 21 to 45 years): 94.8% of respondents
were heterosexual. Of those who completed the survey, 59.4% of the respondents were
women and 50.6% were Caucasian. Additionally, we delineated three age groups to determine
whether age, irrespective of year of enrollment, influenced attitudes toward homosexuality.
We did not ask respondents about their country of origin nor specific year in the
program (Table 1).

Cronbach’s alpha coefficient showed that survey elements were moderately internally
consistent across subscales of gay behavior (.86) and male toughness (.82). However,
scale score reliability for persons and civil rights (.53 and .57, respectively) was
less robust, perhaps due to the low number of questions in those subsections (Table
2). Nearly all respondents endorsed positive attitudes toward gay persons and their
civil rights, though skewed data was obtained for the behavior and male toughness
scales.

However, for some respondents, the thought of two men holding hands or having sex
was more “disgusting” than the thought of a man and a woman engaging in the same acts;
a significant minority of students found homosexuality to be an unnatural form of
sexual expression. A significant portion of respondents exhibited traditional views
on male gender roles with respect to concepts of toughness and aggression (Table 2).

We next sought to determine if respondents from different demographic groups scored
differently. The results evidence disparities in response according to respondents’
demographic characteristics (Table 3).

Discussion

This study provides a comprehensive characterization of attitudes toward gay men endorsed
by students at a large U.S. medical school comprising a diverse student body. The
majority of respondents were affirming of gay men and same-sex behavior. Overt disgust
towards gay men was infrequent. However, most questions in the “behavior” scale had
wide standard deviations suggestive of diverse attitudes. Substantial minorities of
students expressed disgust to gay male behavior that correlated moderately with negative
attitudes regarding civil rights and normative notions of male toughness. The results
of this study reveal the need for assessing and revising current methods of or approaches
to instruction in the care of sexual minorities.

Good doctor-patient relationships require trust and mutual respect. Clinical heterosexism,
the assumption that the patient is heterosexual, interferes with the formation and
maintenance of a healthy doctor-patient relationship, and important opportunities
to engage a gay patient in healthful behaviors are likely to be missed [27]. Though typically covert, biases such as those reported in this study can lead to
subconscious actions. Prejudices have been shown to result in overt antigay behaviors
[28]. More worryingly, disgust toward gay men experienced by health care providers and
respondents to our survey is particularly powerful [29]. Such visceral responses are likely to undermine quality of care and reinforce stigma.

Homosexuality has been considered to be “a natural difference, like left-handedness.”
[30] However, when specifically asked, nearly one-third of medical students responded
either negatively or ambivalently to the statement that male homosexuality is as natural
a form of expression as heterosexuality. Our study demonstrates that some medical
students find gay men and their behavior confusing. Studies have demonstrated the
direct relationship between implicit and explicit measures of bias toward gay men
that is most apparent among heterosexual men and based upon affective responses. Our
study measured explicit bias. By its nature, unconscious bias goes unrecognized by
people who see themselves as tolerant or at least hoping to “extract conformity with
social norms.” [31] Though individuals may feel “comfortable” with LGBT issues in theory, when they are
explicitly presented them, it becomes disconcerting. Educational modules must therefore
explicitly endorse the “normality” of homosexuality.

Our study has several strengths. The survey had a high response rate. Despite this,
it is possible that those who did not respond are less comfortable with discussion
of sexually and prejudice. Our results were consistent with a related study on exposure
to LGBT patients conducted among medical students at the New York University School
of Medicine [32,33]. Our study sought additional components of beliefs about gay men to more comprehensively
evaluate for the presence of bias. Since California is historically politically liberal,
it is likely that a similar survey administered in a more conservative part of the
country would find a higher prevalence of prejudicial beliefs. Although the University
of California, Davis, School of Medicine, is a committed leader in the inclusion of
LGBT issues in the curriculum, a lack of acceptance was found among a significant
minority of students, thus highlighting the need to help students recognize and understand
their own biases for better communicating in a socially- and culturally-appropriate
manner with patients from all sexual orientations, races, ethnicities, and so forth.
There was a discrepancy between the percent of students that let the school administration
know they identified as LGBT (2.3%) and those who identified as such on the survey
(5.3%). This underscores the notion that some students are more comfortable with their
sexuality while others feel less forthcoming.

Several limitations should be considered when interpreting our findings. The results
represent the views of a single medical school student population within the United
States to a single stigmatized group. Our study did not evaluate a respondent’s year
in medical training to determine whether attitudes changed with increased amount of
time in school. Most medical students are in their twenties, making conclusive statements
regarding age and negative attitudes more difficult because the range is more narrow.
The cross-sectional and correlational analyses preclude a broader generalization of
how medical students in the United States and globally frame negative responses to
gay men, and does not characterize their perceptions of lesbians, bisexual or transgender
people, or intersex persons. Given that many questions used the word “disgust,” it
is possible that even higher rates of bias would be seen if less extreme words such
as “discomfort” or “unease” were used instead. In this study, we utilized explicit
measures of bias. The questions exposed self-reported bias, which may not correspond
to privately held beliefs. Some individuals may exhibit negative reactions to those
different from themselves, but will not divulge this information when directly asked
[34]. Future work can augment this study to assess the relationship to beliefs that are
explored through measurement of implicit measures to determine if there are discrepancies
among students in higher education, where disguise of bias may be more apparent [35].

Efforts to address prejudices, among other biases that may be covert, are needed to
facilitate open discussions and thereby improve care. Previous research has shown
that individuals who believe that homosexuality is “congenital” exhibit more positive
attitudes toward sexual minorities. Labeling or constructing groups as different in
speech, appearance, or socio-cultural background has deleterious effects on the ability
to provide sound and culturally-adept treatment [36-38]. Several innovative workshops have been developed that help to address the rich needs
of this underserved group beyond sexual practice and pathology but more are needed
[39]. This includes tackling concepts of gender roles and confronting patient issues that
would otherwise be unspoken.

We show that negative attitudes toward gay behavior were linked to more normative
views on male gender roles, or how men are expected to act. Our study advances medical
education for gay men by supporting the need for lectures to discuss masculinity due
to documented correlations with heterosexism [40]. Changing medical student attitudes cannot be done in isolation and should be a component
of a comprehensive organizational approach that involves leadership and faculty role
models to shape the culture throughout all the clinical and academic venues encountered
by students.

There is considerable evidence that competency in dealing with populations experiencing
health disparities require systematic development of a competency-based curriculum
throughout all of medical school. Developing a comprehensive four-year curriculum
around LGBT health is a critical first step. However, even the presence of LGBT patients
and lectures disseminating facts may not adequately address underlying biases. More
interactive methods that incorporate diverse fields of study, including anthropology
and literature, could be used to invoke empathy. Incorporation of interdisciplinary
efforts in current educational modules may attenuate biases seen not only towards
sexual minorities, but the underserved from various ethnic and social backgrounds.

Conclusion

Our study demonstrates that sexual prejudice is more likely to be found in male and
younger medical students. Because the overall data is not normative, it is difficult
to determine whether there was an overall “positive” or “negative” prejudice. The
first finding is surprising given that most polls on homosexuality show a more positive
attitude among younger respondents. Students may acquire more positive attitudes toward
sexual minorities as exposure to LGBT patients and other life experiences increases
through medical school. Though attitudes toward gay behavior are complex, equality
in the provision of clinical care mandates improved educational interventions. Health
professionals must acknowledge biases they have despite discomfort this may cause.
The survey utilized in this study could be used at other medical schools to assess
the extent of sexual prejudice against gay men and therefore provide impetus to implement
curricular changes in concert with a cultural competence committee. Longitudinal studies
with specific interventions should be explored to determine whether prejudice reduction
strategies could improve prejudicial reactions using introspection and facilitated
clinical encounters. Efforts to increase opportunities to confront and reflect on
biases are needed to avoid perpetuating a prevalent and problematic stigma.

Abbreviations

(LGBT), Lesbian, Gay, Bisexual, Transgender.

Competing interests

The authors have no competing interests, financial or otherwise.

Authors’ contributions

KM designed the study, participated in dissemination and data collection, and drafted
the manuscript. RLK and GTM interpreted the data and drafted the manuscript. MDW carried
out the statistical analyses and drafted the manuscript. FTF oversaw the study and
drafted the manuscript. All authors read and approved the final manuscript.

Acknowledgments

We would like to thank the medical students at the University of California, Davis,
whose participation made this study possible.